Office Use: Date Received: _________ Time Received: _________ Received By: _________ License No.: _________
Medical Marijuana Business License Application
Applicant business name:
Trade name (D/B/A):
___________________________________________________
________________________________________________________
New Medical Marijuana License Application submitted to the
State of Colorado?
Yes
No
Provide copy of the application & fees submitted to the State (check if attached):
City of Durango fee schedule:
Application fee for a new medical marijuana
center OR a transfer of ownership
New license fee for a medical marijuana
center
Operating fee
___________
___________
___________
$2500.00 $2500.00
$2500.00 $2500.00
$5000.00 $5000.00
Background investigation fees:
Every owner or individual with any financial interest in the
applicant (as listed on page 3) is subject to a background
investigation. If no owner resides in the City of Durango,
Colorado, then one business manager is subject to a
background investigation in addition to every owner.
Number of individuals subject to background investigation: ___
Cashier’s check/money order. Cash accepted only by appt.
x$250.00 $ ______
Total: $ _____
Address of premises:
City, state, ZIP:
________________________________________________________
Premises telephone: ____________
___________________________
Business email:
___________________________
License mailing contact:
Mailing address:
Website:
______________________
___________________________________________________
(check if same as
address of premises)
_________________________________________
City, state, ZIP:
Email:
_____________________________________________________________
Telephone: _________________
________________________________
Sales tax mailing contact:
Mailing address:
City, state, ZIP:
Email:
___________________________________________________
(check if same as
address of premises)
_________________________________________
_____________________________________________________________
Telephone: _________________
________________________________
City of Durango Medical Marijuana Business License Application, Page 2
What marijuana license(s) does the applicant currently hold with the City of Durango?
Medical marijuana center
License #:
________________________________
Retail marijuana store
License #:
________________________________
Retail marijuana testing
License #:
________________________________
Other: _______________
License #:
________________________________
None
What marijuana license(s) does the applicant currently hold with the State of Colorado?
Medical marijuana center
License #:
________________________________
Retail marijuana store
License #:
________________________________
Retail marijuana testing
License #:
________________________________
Other: _______________
License #:
________________________________
None
Check here if additional information is provided on a separate sheet.
Applying as (check one):
Corporation
Limited Liability Corporation
Partnership
Association
Individual/Sole Proprietor – Affidavit of Lawful Presence
required for all Sole Proprietorships
City of Durango Medical Marijuana Business License Application, Page 3
If applicant is a corporation, partnership, limited liability corporation, or association (not a
sole proprietorship), applicant must list all officers, directors, partners, and managing
members. In addition, applicant must list any stockholders, partners, members, or
other persons with any financial interest in the applicant.
Home address, city, state,
Name
DOB
Title
% owned
ZIP code
Check here if additional information is provided on a separate sheet.
Has the applicant or any owner, member, business manager, party with a financial interest,
or other person named on this application ever been convicted, entered a plea of nolo
contendre, or entered a plea of guilty in conjunction with a deferred sentence and judgment
pertaining to any charge related to possession, use, or possession with intent to distribute
narcotics, drugs, or controlled substances?
Yes
No
Has the applicant or any owner, member, business manager, party with a financial interest,
or other person named on this application ever been convicted, entered a plea of nolo
contendre, or entered a plea of guilty in conjunction with a deferred sentence and judgment
pertaining to any charge related to driving or operating a motor vehicle while under the
influence of or while impaired by alcohol or controlled substances?
Yes
No
Has the applicant or any owner, member, business manager, party with a financial interest,
or other person named on this application ever been convicted, entered a plea of nolo
contendre, or entered a plea of guilty in conjunction with a deferred sentence and judgment
pertaining to any felony?
Yes
No
If the answer to any of the previous three questions is yes, please provide the following.
Last date of
Individual name/
Charge
Date of
incarceration/
Sentence
location of court
convicted of
sentencing
parole/
probation
Check here if additional information is provided on a separate sheet.
City of Durango Medical Marijuana Business License Application, Page 4
Has the applicant or any owner, member, business manager,
party with a financial interest, or other person named on this
application been denied an application for a retail or medical
marijuana license by any jurisdiction?
Yes
No
Has the applicant or any owner, member, business manager,
party with a financial interest, or other person named on this
application had a retail or medical marijuana license suspended
or revoked by any jurisdiction?
Yes
No
Has the applicant or any owner, member, business manager,
Yes
No
party with a financial interest, or other person named on this
application been denied an application for a liquor license by
any jurisdiction?
If the answer to any of the previous three questions is yes, please provide a detailed
written explanation. (Check if attached.)
By what means does the applicant have legal possession of the premises for at least 1 year
from the date that this license will be issued?
Deed
Lease
Other (explain in detail):
____________________________________________________________________________
____________________________________________________________________________
If premises are leased, the tenant name on the lease must match the name of the applicant
business. List here the names of landlord and tenant, and date of expiration, EXACTLY as this
information appears on the lease:
Landlord:
Tenant:
Expires:
If premises are leased, attach the Landlord’s Consent form, completed by the owner of the
property and notarized. The consent must be specifically for the proposed medical business.
Check this box to indicate that the notarized Landlord’s Consent form is attached.
Are the premises in compliance with all zoning requirements of
the Durango Medical Marijuana Ordinance?
Yes
No
Are the premises to be licensed located within 1000 feet of any
school, addiction recovery facility, or residential child care
facility, or within 250 feet of a dedicated public park that
contains children’s playground equipment?
Yes
No
City of Durango Medical Marijuana Business License Application, Page 5
Additional documents to be submitted for any medical marijuana business applicant.
Documents must follow the relevant requirements set forth in full detail in Ordinance No. O2014-27, Article VIII, Division 2, Sec. 13-204, and elsewhere. Please check each box to
indicate that the document is attached.
Community Development LUP approval
Lease or deed in the name of the applicant business
Proof of Workers’ Compensation insurance for any employee
Proof of Comprehensive General Liability insurance with minimum single limits of one
million dollars ($1,000,000) each occurrence and two million dollars ($2,000,000)
aggregate, applicable to all premises and operations
An operating plan for the proposed establishment, including:
A detailed description of products and services to be provided, including an
indication of whether the establishment proposes to engage in the retail sale of
edible marijuana products
A dimensioned floor plan on 8 ½” x 11” paper
Indication of the maximum amount of marijuana and/or marijuana-infused products
that may be on the business premises
Security plan indicating how the applicant will comply with applicable laws, rules, and
regulations, per Sec. 13-204(h) and Sec. 13-211
Lighting plan, showing the illumination of the outside of the establishment for security
purposes and compliance with applicable city requirements
Vicinity map, drawn to scale, indicating within a radius of ¼ mile from the boundaries
of the property upon which the establishment is located, the proximity of the property
to any school, residential child care facility, addiction recovery facility, or dedicated
public park containing children’s playground equipment, and to any other facilities
required by law
Completed copy of the City of Durango Individual History Record form
Plan for disposal of any medical marijuana or product that is not sold or is
contaminated in a manner that protects any portion thereof from being possessed or
ingested by any person or animal
Plan for ventilation that describes the ventilation systems that will be used to prevent
any odor of marijuana from extending beyond the premises of the business
Description of all regulated toxic, flammable, or other materials that will be used, kept,
or created at the establishment, and the location where such materials will be stored
Copies of state badges for owner(s) and any business manager(s) reported to the state
Certificate of Good Standing from Colorado Secretary of State (entity name must match
applicant business name)
A comprehensive list of vendors and suppliers providing product to the establishment
If the owner is not a natural person, the application shall include copies of the
organizational documents for all entities identified in the application, and the contact
information for the person that is authorized to represent for the entity or entities.
All relevant fees (totaled on page 1 of this application)
City of Durango Medical Marijuana Business License Application, Page 6
Oath of Application
I declare under penalty of perjury in the second degree that this application and all
attachments are true, correct, and complete to the best of my knowledge. I also
acknowledge that it is my responsibility and the responsibility of my agents and employees to
comply with the provisions of the Durango Code of Ordinances and all rules and regulations
which govern my Medical Marijuana Business License Application. I understand that a Medical
Marijuana Business shall not be operated until a license for such use, at the location
designated in the application, has been issued by both the State of Colorado and the City of
Durango. I understand that it is my continuing obligation to update any information on this
application, including contact information, as necessary.
Authorized signature: ________________________________
Date: ____________
Printed name:
Cell phone:
___________________________
Title:
______________________
___________________________
Email:
______________________